LIBRARY OF CONGRESS, 

PRESENTED BY 

UMTED STATES OP AMEEIOA. 



FISKE FUND PRIZE ESSAY 



ON THE 



CAUSATION OF TYPHOID FEVER, 



COMPLIME^^TS 



■OF THE— 



4 






ftgifte if una ptm €mv' 
THE CAUSATION OF TYPHOID FEVER. 




GEORGE E. WAEING, Jr., 

NEWPORT, R. I. 



[Reprinted from The Boston Medical and Surgical Journal, July 18 and 25, 1878.] 




CAMBRIDGE: % 
1878. 



The Trustees of the Fiske Fund, at the annual meeting of the Ehode Island Medical 
Society, held in Providence June 12, 1878, announced that they had awarded a premium of 
two hundred dollars for the best dissertation on The Causation of Typhoid Fever to an 
essay bearing the motto, " Qui n'a santen'a rien ;" and on breaking the seal of the accom- 
panying packet they found the author to be George E. Waring, Jr., of Newport, R. I. 

Chas. H. Fisher, M. D., North Scituate, J 
Edward T. Caswell, M. D., Providence, > Trustees. 
George P, Baker, M. D., Providence, ) 
Charles W. Parsons, M. D., Providence, 

Secretary of the Trustees. 



THE CAUSATION OP TYPHOID FEVER. 



The Ion d; -continued and somewhat thorouo;li investigations of the 
ultimate methods of the causation of this disease have failed of a scien- 
tifically accurate result. The question whether typhoid fever always 
springs from the presence of specific poison produced by a parent case 
of the disease, or whether it may, under certain circumstances, arise 
de novo, is still in doubt. It is hardly worth while, in a paper prepared 
for the use of medical practitioners, to restate the facts and observations 
which support one or the other of these theories ; this would lead only 
to the inconclusive result which has always thus far attended the dis- 
cussion. 

By far the majority seem to sustain the opinion of Dr. Budd and 
his followers, that the disease can originate only from the presence of a 
specific poison produced by a previously existing case. It should be 
remembered, however, that as most physiological investigators have con- 
fined their observations to dense communities, where the disease has 
prevailed, their observations are more or less clouded by the probabil- 
ity that previous cases have had an influence upon those under consid- 
eration. 

Although their number is far smaller, other investigators have de- 
voted themselves entirely to very sparsely settled districts, whose iso- 
lated families have so little communication with the rest of the world 
and with each other that it is easy to determine the exact circumstances 
of contact. The occurrence of typhoid fever in a house standing miles 
away from all others, where it is rare that any member of the family 
goes from home, and where a visitor as rarely comes, furnishes strong 
presumptive evidence of the correctness of Dr. Murchison's theory of 
a possible de novo origin. 

To show the testimony upon which opinions are based, we may cite 
the instances described in various reports of the Massachusetts State 
Board of Health. In that State the annual deaths from this disease are 
about one in one thousand, and it is estimated that one tenth of the 
cases are fatal ; so that about one per cent, of the population are at- 
tacked by the disease. There, as elsewhere, typhoid is peculiarly a 



4 



Tfie Causation of Typhoid Fever. 



disease of the country rather than of the town. The observations of 
ten years show that among a population of 1,044,294 persons, living 
in large towns, the typhoid death-rate was 0.755 ; and that among a 
population of 213,468 persons, living in small towns, the rate was 
1.189. 

The case is reported of a house in Hadley, built by a clergyman, 
where a well existed in the cellar into which foul air from the sink 
drain had access. Vegetables were kept in the cellar ; the windows 
were never taken out ; there was no escape for the foul, damp air ; and 
water stood in drops upon the ceiling and walls. 

" After a few months' residence in the house the minister's wife died, 
of fever, so far as I can learn. He soon married again, and within one 
year of the death of the first wife the second died, from, as I understand, 
the same disease. The children were also sick. He lived in the house 

about two years. The next occupant was a man named B . His 

wife was desperately sick. A physician then took the house. He mar- 
ried, and his wife died of the fever. Another physician was the next 
tenant, and he, within a few months, came near dying of erysipelas. 
All this while matters had remained as before described with reference 
to ventilation. A school-teacher then rented the house, and tore up 
the closed box, but did not cover the well. This was about eight years 
after building the house. The sickness and fatality were so marked 
that the property became unsalable. When last sold every sort of pre- 
diction was made with reference to the risks of occupancy, but, by a 
thorough attention to sanitary conditions, no such risks have been en- 
countered." 

The case of the Maplewood school, at Pittsfield, fully and thoroughly 
reported upon by Drs. Palmer, Ford, and Earle, is too well known to 
be detailed here. Of seventy-four resident pupils, sixty-six had illness 
of some sort ; fifty-one had well-marked typhoid fever. Of the wijiole 
family of one hundred and twelve persons, fifty-six had typhoid fever, 
and sixteen of these died. The cellar was used for storing vegetables; 
the privy vault communicated with the main hall of the building ; the 
kitchen drain discharged near by ; the privy vaults were filled nearly 
to the surface ; and, in the summer season, the house was pervaded 
by foul odors. The school was dismissed ; the sanitary condition of the 
establishment was thoroughly improved, and the institution became and 
has remained free from the disease. 

In a boys' school in Pittsfield the well stood under the wash-house, 
and was fouled by its leaking drain. Coinciding with this condition 
there was a serious outbreak of typhoid. The well being closed, and 
the water supply being taken from another source, the fever subsided. 
In another instance, men engaged in draining a meadow drank from a 
well supplied only from the water of the meadow, and were attacked 



The Causation of Typhoid Fever. 



5 



under circumstances which seemed to connect the disease with the 
drinkino; of this water. In another an attack followed the drinkino; of 
water from a sluggish brook fouled by town sewage. 

Evidence is given in these reports of outbreaks which were traceable 
to the tainting of an air-box, which supplied a furnace, by exhalation 
from the house drain ; by the draining of a mill-pond which contained 
no sewage matters ; and by the proximity of a stagnant ditch which had 
no obvious source of excrementitious fouling. 

In Sutton an outbreak of typhoid coincided with the flow of barn- 
yard waste into a well three rods distant on the occasion of a sudden 
thaw. 

The correspondent from the town of Oxford says : " So firm is my 
belief of this [referring to exhalations from foul drains, cellars, privies, 
and pig-sties] as a cause of typhoid fever that when I meet with a case 
of typhoid fever, not readily traceable to some of these causes, I infer 
that the truth has not been told me, or that my perceptive faculties 
have been at fault." 

At Martha's Vineyard and in Newton there seemiS to be evidence 
that the prevalence of typhoid is effected by geological conditions, clay 
subsoil or underlying rock covered with rich soil favoring the disease. 
The very local character of most epidemics indicates defects of soil 
rather than of air. A physician in Pittsfield reports four cases and one 
death occurring among charcoal burners occupying two houses standing- 
high up on the mountain side, and supplied with pure spring water. 
The first case had been exposed to no other than local agencies. The 
house was built into the hilbside, and on its upper side there was a foul 
pool of house-slops standing several feet higher than the level of the 
floor. This seemed to have caused the first attack of the disease, which 
subsequently extended to the other house, there being frequent com- 
munication between the two. The outbreak took place in August, 
when the windows overlooking this foul water were probably kept open. 
At Coltsville, slops were thrown out near the well, and a foul barn-yard 
pool stood near it. The condition of the well was the only traceable 
cause of the disease which followed. In another case the fever oc- 
curred after the use of water from a well near a barn-yard. Indeed, in 
all of the records of typhoid investigations, here and abroad, there 
appear innumerable instances where drinking-water wells were contam- 
inated by infiltrations from manure heaps, swill, slops, cesspools, and 
privy vaults. In other cases, where there has been no conspicuous con- 
tamination of the drinking-water, outbreaks of the disease have coin- 
cided with the emptying of mill-ponds for the purpose of repairing the 
dams. Again, the infection of well-water by the infiltration of soap-suds 
in which the clothing of fever patients had been washed seems to have 
caused an outbreak. 



6 



The Causation of Typhoid Fever, 



One of the most striking examples of investigation of the astiology of 
typhoid fever occurring in very sparsely settled districts is to be found" 
in a paper by Dr. W. H. Bramblett, of Newberne, Va., published in 
the Virginia Medical Monthly^ Ma}^ 1877, page 109. Dr. Bramblett 
practices along both sides of New River, which flows through a mount- 
ainous country broken into numerous valleys and gorges. There are 
no ponds or marshes whatever, and the elevation is from twenty-two 
hundred to twenty-five hundred feet above the sea. His investigations 
lead him to the belief that typhoid fever may originate without the 
least possible connection with a previous case. He cites seventeen 
cases, which had seven distinct starting-points, entirely unconnected 
with one another and with any other traceable source of contagium. 
The drinking-water seems to have been always pure, mountain-spring 
water ; the privies appear to have been well placed with respect to the 
house ; and, so far as can be gathered from Dr. Bramblett's report, there 
was an entire absence of all of the conditions wdiich usually attend out- 
breaks of this disease. The description of symptoms indicates that the 
cases w^ere all true typhoid fever. Among his conclusions Dr. Bramblett 
suggests the following : that " typhoid fever often originates spontane- 
ously," or that the contagium to which the disease owes its specific 
character originates de novo.^^ 

In estimating the value of this report it is to be considered that the 
reporter believes typhoid fever to be directly contagious, — a conclusion 
diametrically opposed to the recorded observations of those who have 
had experience in great fever hospitals. 

While the voluminous records of investigation as to the origin of 
typhoid fever fail utterly to decide the question between those who do 
and those who do not believe that it can originate de novo, and while 
they leave in doubt the question between " living germ " and " specific 
poison," — while, in other words, they leave the purely scientific prob- 
lem still unsolved, — they are full of instruction as to the causation of 
the disease as we almost uniformly know it in practice. From the 
point of view of the medical practitioner, although much is still to be 
learned, we already know enough for the complete stamping out of 
typhoid fever as an epidemic. Sporadic cases may still occur, but if 
the physician knows what he may now learn, if he is energetic in the 
performance of his duty, and if he is sustained by private opinion and 
by public authority, he may, in every instance, prevent the extension of 
the disease to a second subject. Practically, so far as the health of the 
public is concerned, we may be said to possess already very nearly all 
the knowdedge that we need. 

There is no longer any dispute concerning the chief vehicles by 
which the specific contagium of typhoid fever is conveyed. These are 
the air that we breathe and the liquids that we drink. Perhaps we 



The Causation of Typhoid Fever. (j) 



may narrow the question still more, and ascribe to the action of the air 
only the indirect conveyance of tlie contagium to the stomach ; for there 
are indications that as the contagium of typhoid fever proceeds from 
disorders of the alimentary canal, so it is only the surfaces of the ali- 
mentary canal which are susceptible to its attack. 

The poison of the air may be direct or indirect. That is, it may be 
due to the exhalations of decomposing matters in dung-heaps, pig-sties, 
privy vaults, cellars, cess-pools, drains, and sewers ; or it may be due 
(according to Pettenkofer) to the development of the poison deep in 
the ground, and its escape in an active condition in ground exhalations. 
The water, milk, etc., which we drink may be contaminated by the ab- 
sorption of foul odors from air with which they are in contact, or by the 
direct admixture of organic matters bearing the elements of infection. 
There is such a multitude of possible sources and channels by which 
the infection may be brought to us that it is often almost impossible, in 
first cases, to determine which has been actually in operation ; but the 
original case being established, it becomes comparatively easy to trace 
the channel of its influence in the production of further cases. 

It is with these well-known and clearly traceable agencies of develop- 
ment and communication, by which the initial causation is favored and 
the extension of the disease insured, that the practicing physician and 
the health officer have chiefly to do. If it is true that prevention is- 
better than cure, then it should be the first care of the physician tO' 
insure the absence of all conditions which do or may favor the origin 
and spread of the disease. 

Typhoid fever has in this connection an especial importance, not 
only as being a wide-spread scourge of almost unequaled magnitude,, 
but as being the typical " pythogenic " disease. Its development and 
extension are due to conditions which equally promote the spread of diph- 
theria, diarrhoea, dysentery, cerebro-spinal meningitis, scarlet fever, and 
the long list of minor ailments which, without destroying life, make- 
living almost worthless, — diseases which undermine happiness, sap' the 
springs of energy, and overwhelm the patient with listlessness and 
ennui. It is the best known and the most widely spread of the long 
list of preventable diseases ; and as the circumstances which favor the 
extension and ao-o-ravate the character of the whole of these are those 
wdiich have the strongest influence over itself, so by removing the con^ 
ditions wdiich foster them w^e shall do much to restrict its contao-ion. 
// All the learnincj of the ao^es has tauo;ht us no better formula to ex- 
press a perfect sanitary environment than the old one of Hippocrates i 
" Pure air, pure water, and a pure soil." 

If we would turn typhoid from our doors, and literally stamp it out as> 
an epidemic, we need only to insure this condition in its integrity. We 
may still import single cases from less cleanly neighborhoods, but it 



8 



The Causation of Typhoid Fever. 



will be our fault if we permit it to attack even one of our own commu- 
nity. 

Turning now to the practical bearings of the question, we may safely 
assume that typhoid fever is not conveyed by simple personal contact 
with the diseased body. According to Dr. Murchison, in the London 
Fever Hospital, where two thousand five hundred and six cases of 
typhoid fever were treated in fourteen and one half years, there oc- 
curred during the whole time only eight cases which originated in the 
hospital. Other instances are almost as striking, and in some cases the 
disease originated in isolated wards, such as small-pox wards, where 
personal contact was impossible, but where a conveyance of the infec- 
tion by drains, air channels, etc., was clearly detected. 

It may doubtless be assumed that the agency in the spreading of the 
disease from an original case exists entirely in the dejections from the' 
bowels. Dr. Budd thinks that the surface of the bowels throws off the 
specific poison, as the surface of the skin throws off the poison of other 
diseases. The infecting material, whatever may be its character, is 
believed never to be active until it has undergone, a certain develop- 
ment in connection with subsequent fermentation or decomposition of 
the dejections. Its vitality is very great, and seems little dependent 
upon circumstances other than the effect of a very high temperature. 
Dr. J. M. Lazzell, in the Transactions of the Medical Society of West 
Virginia for 1877, pubhshes a paper on the contagiousness of typhoid 
fever, in which he describes an outbreak in the family of one Thomas, 
wdiich in time produced such terror that no nurse or washer-woman 
could be induced to come to the house. The bed linen and clothing, 
soiled with typhoid dejections, were boxed up and packed away. Three 
months after the disease had disappeared from the country, and when 
the general health was good, a girl came from six miles distant to do 
the house-work. Among other things she washed this boxed-up cloth- 
ing. In ten or twelve days she was taken sick, and went home. Dr. 
Lazzell was called to her five days later, and recognized the same form 
of typhoid fever that had occurred in the Thomas family. Eleven 
members of her household were exposed, and eight of them took the 
disease. It did not attack a single person not so exposed. 

The evidence is copious and conclusive that typhoid infection is 
transmitted often to a long distance, and after the lapse of considerable 
time, by running water to which the dejections have obtained access. 

In Wicken Bonant the stools of a typhoid patient were thrown into 
a vault which stood near to the edge of a brook thirty-five yards above 
the parish well. The water-course carried the infection to the well. 
Forty-five cases occurred : five of them among one hundred and eighteen 
persons who did not drink water from the well, and the remaining 
forty among eighty-eight persons who had no other source of water 



The Causation of Typhoid Fever. 



9 



supply. That is to say, of those who used the water from the parish 
well forty-six per cent, were attacked, and among those obtaining water 
from other sources less than three per cent, were attacked. This state- 
ment is taken from the twelfth report of the medical officer of the privy 
council of E norland. 

I have previously cited the case of the outbreak at Over Darwen, in 
England, as follows : — 

" There has recently been an investigation into the origin of an out- 
break of " filth fever " in Over Darwen, England, the origin of which 
for a long time eluded the careful search of the authorities. It was 
finally worked out by a sanitary officer sent from London. The first 
case was an imported one, occurring in a house at a considerable dis- 
tance from the town. The patient had contracted the disease, came 
home, and died with it. On first inquiry it was stated that the town 
derived its water supply from a distance, and that the water was brought 
by covered channels, and could not possibly have been polluted by the 
excreta from this case. Further examination showed that the drain of 
the closet into which the excreta of this patient w^ere passed emptied 
itself through channels used for the irrigation of a neighboring field. 
The water-main of the town passed through this field, and, although 
special precautions had been taken to prevent any infiltration of sew- 
age into the main, it was found that the concrete had sprung a leak 
and allowed the contents of the drain to be sucked freely into the 
water-pipe. The poison was regularly thrown down the drain, and as 
regularly passed into the water-main of the town. This outbreak had 
a ferocity that attracted universal attention ; within a very short period 
two thousand and thirty-five people were attacked, and one hundred 
and four died." 

Liebermeister says that typhoid dejections, conveyed in night-soil 
spread as manure upon the gathering ground of an aqueduct, so con- 
taminated the water supply as to produce an epidemic of typhoid fever 
among the population using the water. 

Similar instances mio-ht be cited almost without number. Indeed, 
there is among investigators no difference of opinion as to the com- 
munication of the disease by means of drinking-water thus polluted. 
There are many instances recorded of the contamination of the water 
of wells by the transmission of faecal matters through the soil from ad- 
jacent privy vaults and cess-pools. One of the most striking of these 
is that of an outbreak in the village of New Boston, in Erie County, 
N. Y., in 1843, investigated and reported upon by Dr. Austin Flint, 
Sr. From its early date this case is worthy of description here. No 
case of typhoid fever had ever been known in the county. The com- 
munity numbered forty-three persons ; twenty-eight of these were at- 
tacked with fever, and ten died. All of those affected obtained their 



10 



The Causation of Typhoid Fever. 



drinking-water from a well adjoining the tavern ; but one family, living in 
the midst of the infected neighborhood, owing to a feud with the tavern- 
keeper, did not drink this water, and escaped infection. Two families 
lived too far away to use this well. This immunity on the part of the 
enemy of the tavern-keeper led to a charge that he had maliciously 
poisoned the well, — a charge which resulted in a suit for slander and the 
payment of one hundred dollars damages. At that time the idea that 
typhoid fever might be communicated by infected drinking-water had 
not been advanced ; but its truth receives strono; confirmation from the 
fact that a passenger, coming from a town in Massachusetts where 
typhoid prevailed, and traveling westward in a stage-coach, having been 
taken ill, was obliged to stop at tliis tavern. Twenty-eight days after 
his arrival he died of typhoid fever, and thus, doubtless, transmitted 
in some way to the water of this well the germs of the disease, which 
speedily attacked every family in the town except the three wliich did 
not resort to it for their supply. 

Not only does water itself serve as the direct vehicle of contagion, 
but it has, in several striking instances, caused the serious contamination 
of milk which had been directly diluted by it, or which had been stored 
or carried in vessels washed with it. The most noteworthy of the re- 
ported cases of this character is that of an outbreak in Marylebone and 
the adjoining parts of London, reported by Radcliffe in the second 
number of tlie new series of reports of the medical officer of the privy 
council. Two hundred and forty-four cases were distributed through 
one hundred and forty-three households. There was at that time no 
corresponding increase in neighboring districts, and the metropolis gen- 
erally was unusually free from typhoid. The conclusions arrived at 
were the following : (1) the outbreak was caused by milk infected with 
enteric fever material ; (2) this milk came from a particular farm ; 
(3) the water used for dairy purposes on this farm contained excre- 
mental matters from a patient suffering from enteric fever immediately 
before and at the time of the outbreak. Of one hundred and ninety- 
one cases occurring in nine weeks, one hundred and sixty-seven were in 
households taking this milk, and only twenty-four in households not 
taking it. 

All evidence points to the long vitality of the infecting material, 
which lies dormant at times for many months, and then, under favor- 
ins; circumstances, acts with violence. 

Not only does the infection follow the course of water to which it 
has sained access, or find its means of dissemination in the exhalations 
of decomposing filth, and thus contaminate the air which we breathe, 
but these exhalations are readily absorbed by water, which is capable 
of holding the poison, to the detriment of those who may drink it, and 
of transmitting it again to air with which it may be in contact. Many 



The Causation of Typhoid Fever, 

cases have been reported similar to that cited by Dr. Carpenter, health 
officer of Croydon, who traced the origin of an outbreak to the drink- 
ing of water from a house cistern, to which air from the public sewer 
had been led by the pipe serving as an overflow for the cistern. 

Especial danger attaches to the use of water-traps, or water held in 
the bends of waste-pipes, soil-pipes, etc., when these are the only bar- 
rier between the interior of the house and a sewer or cess-pool contain- 
ing typhoid dejections. The retained water absorbs the poison at its 
outer or sewer end, becomes saturated with it, and gives it off to the 
air ip the house end of the pipe. 

% Tiie conclusion from the foregoing is clearly this : that the dejections 
of typhoid patients are always* to be regarded as dangerous material, 
capable of developing and spreading the fatal infection under a great 
variety of conditions ; that the only sure means for preventing the 
spread of the disease must be sought either in the speedy, complete, 
and distant removal of the material, or in its complete disinfection. 
If to be retained in the vicinity of human habitations, it must be dis- 
infected, or subjected to decomposition, under such conditions that its 
poisonous material shall be destroyed ; if to be removed, it must be 
removed to a point beyond the reach of the community, and to a point 
where it can in no wise contaminate the source from which drinkino;- 
water is taken. 

The contagium of typhoid fever is not a poison in the sense in which 
strychnine and arsenic are poisons, — attacking alike each body into 
which it may be introduced, — but, like the contagium of other diseases 
of its class, it depends upon a certain condition of susceptibility on the 
part of the subject. This infection, like many others, is inoperative 
except upon a system prepared to receive it. In other words, we must 
have not only the seed but also the soil. In discussing the causation of 
this disease with the practical object of seeking the means for its pre- 
vention, we have to regard not only the source of the contagium, the 
vehicles of its transmission, and the method of its attack, but in almost 
equal degree those influences which tend to dispose the human body 
to succumb. This double condition (that there must be, if not abso- 
lutely always, at least very generally, an actual element of contagion, 
whether germ or specific poison, and also that there must be a state of 
susceptibility on the part of the subject) greatly improves our chances 
of success in contending with the disease. We know where the mor- 
bific material resides, and so are enabled to avert its approach ; and, 
on the other hand, we know what conditions of living induce the sus- 
ceptibility, and so have it in our hands, by improving these conditions, 
to increase the power of resistance. 

So far as the prevention of typhoid fever is concerned, aside from 
tonic medication, the means to be employed are of a purely hygienic 



12 



The Causation of Typhoid Fever. 



character ; it is a question of the skill of the practitioner as a sanitarian 
rather than as a physician. He has two objects to attain : first, the 
removal of the infecting cause ; second, the provision of healthful con- 
ditions of living. If the theory is correct that, as Dr. Murchison sup- 
poses, typhoid fever may originate de novo from the decomposition of 
organic matter, then the two objects are to a certain extent blended, in 
so far as atmospheric conditions, which might induce susceptibility, are 
also capable of causing the disease. In effect, our practice will be 
safely guided if we regard the two objects as separate and distinct. 

Starting with the proposition that typhoid fever is produced only by 
the operation of a specific cause borne in the dejections of typhoid pa- 
tients ; that it is innocuous when first voided, but becomes active after 
a certain exposure in the decomposing fseces ; that it has great vitality ; 
that it is capable of being carried by flowing water, by water perco- 
lating through the earth, and by the vapor of water floating in the 
air ; that it may be absorbed and retained and exhaled by water ; and 
that it may be retained, developed, and transported by clothing and 
other articles soiled by its medium, we see that the greatest possible 
vigilance and the most skillful care are to be applied to the treatment 
of typhoid dejections. Some of the experiences of England indicate 
the truth of the statement of the Rivers Pollution Commissioners, that 
so far as the cause of infection is concerned " filters do not filter and 
disinfectants do not disinfect." It will at least be safe to assume that 
in the case of water-carriage the immediate distant removal and the 
most complete atmospheric exposure are much more effective than 
any treatment of sewage by the usual methods of filtration ; also, that 
any attempt at chemical disinfection must be more than ordinarily 
thorough. There is reason to suppose — reason almost suflicient to 
secure reliability — that the poisonous element is developed and made 
effective only when the decomposition of the faeces containing it takes 
place in the absence of a supply of fresh air sufficient to carry it on 
in the most rapid and healthy way. In other words, active oxidation, 
whether produced by oxidizing disinfectants, by the operation of atmos- 
pheric oxygen, or by the intensified oxidizing power of the contained 
gases of porous material, seems to prevent decomposing faeces from as- 
suming a condition favorable to the development of infection. The 
evidence in support of this theory is of course of a negative character, 
but it is extensive, and, so far as the writer knows, it is accepted by 
leading physiologists. 

Typhoid fever is not produced by exhalations from the surface of 
lands irrigated with the discharge of such sewers as have a rapid and 
continuous flow, and thereby deliver all they receive before it has had 
time to undergo decomposition. There is no evidence that typhoid 
fever is caused by the contained air of thoroughly ventilated soil-pipes. 



The Causation of Typhoid Fever. 



13 



The most active professional enemies of the earth-closet system have 
never adduced an instance where typhoid fever, or any other cog- 
nate disease, has followed its well-regulated use. In The Lancet of 
March 6, 1869, Professor Eolleston, setting forth his objections to the 
earth closet, said : " If I am told that the earth closet is inoffensive, 
and that the privy is foetid, I answer that a rattlesnake is none the less 
dangerous because its rattle is removed ; and that, for anything shown 
or known to the contrary, odor is to infection, deodorization to disinfec- 
tion, what the noise of the serpent is to its bite." It is nine years since 
this was written, and amid all the voluminous reports upon the dry- 
earth system there is no word to sustain Dr. Rolleston's fears. On the 
other hand, together with much else of similar purport, the evidence of 
Dr. Monat reports that in those jails of India where the earth system 
is used, even at the time of the most serious cholera epidemics, this dis- 
ease, which is so like typhoid in its mode of transmission, never gains a 
foothold. One would almost be justified in replying to Professor Rolle- 
ston, that it is not a question of removing the rattle, but of killing the 
snake. Investigations made to determine the manurial value of closet 
earth used many times over indicate a total and absolute destruction, 
not only of the odor but of the whole combustible material of the added 
faeces. The result has shown as complete destruction as would attend 
burning in a furnace. 

This destructive oxidation depends upon the well-known concentra- 
tion upon the surfaces of the interior particles of aerated porous sub- 
stances. The intensity of the action is in proportion to the fineness of 
the material, or, in other words, to the total area of its interior surfaces. 

It is perhaps not safe to assume that', in dealing with such dangerous 
material as typhoid excreta, treatment with dry earth, or ashes, or char- 
coal will suffice to render it harmless, but it will be more effective in 
this direction than anything else of which we have knowledge, and will 
at least prepare it for safe removal. 

The physician in considering the treatment of the material in question 
has one of two sets of conditions to deal with. The fsecal wastes of the 
household which he is attending are either removed by water-carriage, 
or thrown into privy vaults. If by water-carriage, they are delivered 
into a public sewer or into a cess-pool. Sewers, as they usually exist, 
and cess-pools always and invariably, are so circumstanced as to favor 
the thorough development and multiplication of the morbific material 
under consideration. Unfortunately, sewers and cess-pools are so con- 
nected with the interiors of houses, with others as well as with that 
where the disease oriorinated, as to make them too often the means for 
converting a sporadic case into a centre of infection. Even the house 
drains and soil-pipes through which the excrement passes on its way to 
the cess-pool or sewer are very generally as bad as these final recepta- 



14 



The Causation of Typhoid Fever, 



cles themselves, while almost always the only barrier to the free re- 
turn of their air and its poisonous freight into our very living rooms is 
the water retained by a depression in the pipe (the trap), which water 
constantly absorbs and transmits the gases presented to it. 

Where these water barriers are supplemented with one of the many 
mechanical check valves recently introduced, this means for the return 
of the infection is shut off. Where the soil-pipe and drain are freely 
open at both ends for the transmission of a current of atmospheric air, 
the danger of the development of the poison is greatly reduced, if not 
entirely removed. But even here, although we may feel secure so far 
as the immediate household in question is concerned, it is to be remem- 
bered that, at least in the case of a pubKc sewer and of a cess-pool com- 
mon to several houses, the matter deposited may produce its injurious 
effect in other families which are less well protected against it. Even 
where the cess-pool is connected with one house only, to permit the spe- 
cific poison of typhoid fever to enter it and to spread itself through its 
accumulated filth is to incur a danger akin to that of estabhshing a gun- 
powder vault in one's back yard. 

When infected faeces are to be thrown into a water-closet or drain 
thev should at least be treated with the stroncrest and most destructive 
chemical disinfectants, carbolic acid being by no means sufficiently so. 

When the faeces of the household are received in a priv}^ vault, it 
must be accepted as an imperative rule that typhoid dejections must 
never, under any circumstances, find access to this. Abundant and 
conclusive evidence shows that such accumulations of f^ces only await 
the introduction of the least germ of any diarrhoeal disease to become, 
by means of their exhalations and of their pollutions of the soil, active 
agencies of development. 

Even when the earth-closet system is employed, none of the regular 
apparatus should be used by the patient, or become the receptacle of his 
dejections ; this for the simple reason that it should be our first object 
to secure the most complete isolation of the tainted matter from every 
substance which might foster the increase of its tainting element. 

It would be. better, perhaps, to stop with this general statement of 
principles, leaving each practitioner to apply them according to his 
judgment, but one is tempted to recommend what one believes to be the 
most efficient process, and I therefore take the liberty of suggesting 
that a chamber or bed-pan, filled to the depth of an inch with dry earth, 
or with sifted anthracite ashes, or with powdered charcoal, be used to re- 
ceive the evacuation ; that this be immediately covered with a further 
inch in depth of dry material, and that the whole be turned into a shal- 
low hole in the ground and covered with earth not more than two inches 
deep, so that it may go through with its decomposition in the upper soil 
within easy reach of the oxidizing air. If to be removed quite away 



The Causation of Typhoid Fever, 



15 



from the premises, the earth containing the dejections may be thrown 
into a barrel or box, each deposit being covered with fresh earth, and 
car.ef ully protected against rain. 

It would be out of place here to enter into all the details of the hy- 
gienic law. In a paper written for the profession this would be, too, a 
work of supererogation. At the same time it may be advisable, in this 
connection, to refer briefly to the manner in which, and the degree to 
which, the general health is influenced by exhalations from decompos- 
ing organic matters in sewers, house-drains, vaults, cess-pools, and cel- 
lars. It must have been the frequent experience of all physicians that 
every question as to the tainting of the air of a house from these sources 
is met by the assertion that no bad smell has ever been perceived. In 
the first place, the accustomed nostril is dull to detect a constant odor, 
and in the next it is hard to make people believe that, where they can 
smell no offense, there still may be danger. We ourselves know that 
the juices of the cadaver are most fatally dangerous before offensive 
decomposition has set in. Those who have given attention to the influ- 
ence of drain-air in causing disease know very well that the action of 
this upon the health bears no relation to the intensity of its accompany- 
ing odors. 

The only safety is to be sought in the absolute freedom of the air 
that is breathed, and of the water that is drunk, from every species of 
contamination due either directly or indirectly to organic decomposi- 
tion. A little rift in the waste-pipe of a wash basin, so slight as to be 
detected only by the application of tissue-paper, has kept a whole fam- 
ily miserable and complaining, and susceptible to every species of conta- 
gion, for years together. Decaying vegetables in a cellar, and decay- 
ing filth in the waste-pipe of a kitchen sink, may be regarded as the 
bane of the existence of half the women in America. Those more 
serious defects which come of ignorantly arranged plumbing work — 
by no means of good plumbing work, which is the sanitarian's best aid — 
are responsible not only for most of the zymotic diseases appearing in 
the better class of houses, but in like degree for the generally ailing 
condition of so many of those who pass most of their days and nights 
in these houses. 

The regulation of all these helps to healthful ness is a matter of de- 
tail which may well engage the best attention of the profession. Even 
the cataloguing and classification of the subject here would be impos- 
sible. The fundamental principle should always be borne in mind that 
neither in a sewer, nor in a cess-pool, nor in a house-drain, nor in a soil- 
pipe, nor in the smallest waste-pipe should decomposition be allowed to 
proceed without such an abundant presence of fresh air as will secure its 
most rapid and complete progress. The same condition of obstructed de- 
composition which fosters the development of infecting agencies is pre- 



16 



The Causation of Typhoid Fever. 



cisely that which leads to a generally unwholesome and debilitating at- 
mosphere. All investigation of this subject, and all discussion of the 
modus operandi by which unwholesome influences lead to the spread of 
epidemic diseases and to the lowering of the general health, bring us at 
the end to a firm belief in the principle covered by Hippocrates's pre- 
scription : pure air, pure water, and a pure soil. 



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